Are Pediatric Guidelines for Statins Too Aggressive?

If, instead of following the adult guidelines, doctors used pediatric guidelines to identify teens with high LDL-levels, and if universal screening was in place, another 400,000 adolescents would be taking statins. Would that increase be good or bad? Doctors disagree. Some suggest that the increased treatment would be premature and dangerous to teen health.  Results from a study, which used the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey, published today in JAMA Pediatrics, found that about 2.5% of teens 17-21 would satisfy the pediatric statin guidelines, compared with 0.4% using adult criteria.

“The safety of statins [in this population] is completely speculative and theoretical,” said Rodney Hayward, MD, Director of the Robert Wood Johnson Clinical Fellows Program, at the University of Michigan Ann Arbor. “We really need good evidence of benefit before we take a risk like this with adolescents.”

What concerns Hayward is a trend for specialists, in this case, pediatric cardiologists, to favor aggressive treatment before the burden of proof is satisfied. “There is a tendency to view everything as safe until we have the new Vioxx.” The teen brain is still developing. Given associations between statins and cognitive problems, Hayward questions whether giving statins could have adverse neurologic effects. Statin’s effects on neurologic tissue are also concerning. It would be best if teens were physically active. Adverse muscle effects have also been identified with statin use. This is just at the time when you want kids to be physically active.

One possible exception for statin use that Hayward would use is an extremely high LDL level. He also acknowledged that there is some evidence that testing adolescents once every five years may derive benefit. Hayward still thinks that benefit would be gained if statins were begun later, perhaps at age 35.Statin benefits do not accrue until years later.

The authors urge doctors to use shared decision making in cases of uncertainty because people vary in what risks that they want to take. To my knowledge, no studies of shared decision making in evaluating whether or not to put your kids on statins have been done. I wonder whether prescribing pediatric cardiologists can present the knowns and unknowns without bias.

Back Pain Treatment Trends Worth Reversing

It may just be the American way –pull out all the stops and try anything or everything at great expense when it comes to medical care.

Today’s post takes up how well the United States is doing at providing back pain care in accordance with evidence-based clinical practice guidelines for back pain (including neck pain). In original research and a commentary published online July 29, 2013 in JAMA Internal Medicine, John N. Mafi, MD, and coauthors from Beth Israel Deaconess Medical Center and Harvard Medical School, in Boston, MA, point out troubling trends in back pain care using nationally representative data from the Centers for Disease Control and Prevention’s National Ambulatory Care Survey and the National Hospital Ambulatory Care Survey.

Back pain is common, with surveys showing that 65% to 80% of Americans will report back pain at some point in their lifetime. So understanding what’s going on and managing it with the best science sounds good for patients. Back pain is a loaded category for sure: it involves how well patients can tolerate pain, patience because back pain is often temporary, yet it can be a springboard for all sorts of referrals. There are some relatively inexpensive ways to manage back pain that get a grip on back pain, but the study discussed here suggests that people want to throw everything at it and that the care people are getting is moving afield from science-based guidelines.

Prescribing Patterns

oxycontinBetween 1999 and 2010, opioid use for back pain climbed substantially from 19.3% to 29.1%, while recommended nonsteroidal anti-inflammatory drugs (NSAIDs: e.g. ibuprofen) and acetaminophen have declined by nearly half, from 36.9% to 24.5%.  The latter two drug categories are recommended as first-line for patients with back pain. Additionally, doctors in the south and west prescribed narcotic medications about 1.5 times more frequently than doctors nationally.

Not everyone gets opioids prescribed. The odds that women, black, Hispanic, and other racial/ethnic groups, and the uninsured were prescribed opioids was significantly lower. Commenting on this disparity, Richard Deyo, MD, MPH, Kaiser Permanent Professor of Evidence-Based Family Medicine, Oregon Health Sciences University, Portland, OR, said: “I think this is a situation where good insurance – and greater affluence – make overuse more likely. This may be a case where underinsurance has a protective effect!”

Imaging

MRI machine

MRI machine

Subgroup analyses revealed that neurologists and orthopedic surgeons had a far greater odds of ordering CT and MRI: more than 3.5 times higher than primary care doctors. MRI scans and CT scans rose between 1999-2000, at 7.3% to 11.3%, in 2009-2010.

Referrals

Physical therapy referrals remained constant over the ten-year period, but referrals to other doctors, especially neurologists and orthopedists, doubled by 6.8% in the first year of data collection to 14.0% in 2009-2010.

One Limitation: No Surgery Data

 The data are limited in that this data set cannot be used to see whether or not people got surgery.  However, lots of previous research suggests that with the cascade of advanced imaging and physician referrals, people are getting surgery more frequently.

What About Patients?

 In this study, trends in management of back pain suggest care is moving away from science-based medicine. Many of us have endured back pain that feels acute or chronic. Some of us know people who have had back surgery, seen lots of doctors, and gotten imaging studies. As I write this post, the news is calling attention to premiums perhaps not being that high as predicted with Obamacare. But you have to wonder: if these patterns of overuse to no good end for patients persist, the costs are going to get thrown back to patients. I’ve said this before, but I think we are at a standstill. We need to move beyond documenting overuse and inappropriate use and come up with ways to get doctors and patients on board with what works and does not.